Patient Preferences for Postmastectomy Breast Reconstruction
Authors: Ronnie L. Shammas, Anna Hung, Alexandria Mullikin, Amanda R. Sergesketter, Clara N. Lee, Shelby D. Reed, Laura J. Fish, Rachel A. Greenup, Scott T. Hollenbeck
Journal: JAMA Surgery (2023)

<h3>Importance</h3> Up to 40% of women experience dissatisfaction after breast reconstruction due to unexpected outcomes that are poorly aligned with personal preferences. Identifying what attributes patients value when considering surgery could improve shared decision-making. Adaptive choice–based conjoint (ACBC) analysis can elicit individual-level treatment preferences. <h3>Objectives</h3> To identify which attributes of breast reconstruction are most important to women considering surgery and to describe how these attributes differ by those who prefer flap vs implant reconstruction. <h3>Design, Setting, and Participants</h3> This web-based, cross-sectional study was conducted from March 1, 2022, to January 31, 2023, at Duke University and between June 1 and December 31, 2022, through the Love Research Army with ACBC analysis. Participants were 105 women at Duke University with a new diagnosis of or genetic predisposition to breast cancer who were considering mastectomy with reconstruction and 301 women with a history of breast cancer or a genetic predisposition as identified through the Love Research Army registry. <h3>Main Outcomes and Measures</h3> Relative importance scores, part-worth utility values, and maximum acceptable risks were estimated. <h3>Results</h3> Overall, 406 women (105 from Duke University [mean (SD) age, 46.3 (10.5) years] and 301 from the Love Research Army registry [mean (SD) age, 59.2 (11.9) years]) participated. The attribute considered most important was the risk of abdominal morbidity (mean [SD] relative importance [RI], 28% [11%]), followed by chance of major complications (RI, 25% [10%]), number of additional operations (RI, 23% [12%]), appearance of the breasts (RI, 13% [12%]), and recovery time (RI, 11% [7%]). Most participants (344 [85%]) preferred implant-based reconstruction; these participants cared most about abdominal morbidity (mean [SD] RI, 30% [11%]), followed by the risk of complications (mean [SD], RI, 26% [11%]) and additional operations (mean [SD] RI, 21% [12%]). In contrast, participants who preferred flap reconstruction cared most about additional operations (mean [SD] RI, 31% [15%]), appearance of the breasts (mean [SD] RI, 27% [16%]), and risk of complications (mean [SD] RI, 18% [6%]). Factors independently associated with choosing flap reconstruction included being married (odds ratio [OR], 2.30 [95% CI, 1.04-5.08];<i>P</i> = .04) and higher educational level (college education; OR, 2.43 [95% CI, 1.01-5.86];<i>P</i> = .048), while having an income level of greater than $75 000 was associated with a decreased likelihood of choosing the flap profile (OR, 0.45 [95% CI, 0.21-0.97];<i>P</i> = .01). Respondents who preferred flap appearance were willing to accept a mean (SD) increase of 14.9% (2.2%) chance of abdominal morbidity (n = 113) or 6.4% (4.8%) chance of complications (n = 115). <h3>Conclusions and Relevance</h3> This study provides information on how women value different aspects of their care when making decisions for breast reconstruction. Future studies should assess how decision aids that elicit individual-level preferences can help tailor patient-physician discussions to focus preoperative counseling on factors that matter most to each patient and ultimately improve patient-centered care.